onewikiaorg-20200213-history
Stroke Management
Acute Management of Stroke The goals of acute management of stroke are as follows: 1. Make sure patient’s condition is stable *Check the airway, breathing and circulation 2. Reverse conditions that could contribute to the patient’s neurological symptoms *Essential points to note in HX and PE **Onset time of ischemic stroke symptoms- determines tx w IV thrombolytics (window period= less than 3h from stroke onset) **Course of symptoms over time **Hemorrhagic or ischemic stroke ***Hemorrhagic- pt vomiting, headache ***Ischemic- no vomiting, no headache **Differentials: R/O seizures (bite tongue), syncope, migraine, hypoglycemia, epilepsy **Drug HX: R/O anticoagulant treatment!!!, drug overdose, oral hypoglycaemic agents **PE: neurological examination (NIH stroke score), Look for embolic source 3. Investigation *Priority 1: Decide if this is an ischemic or hemorrhagic stroke **Priority Ix: (Emergent brain imaging with CT or MRI) *Priority 2: Cardiac monitoring in 24 hours **Detect concomitant MI (stroke and MI come tgt) *Other impt ix: serum glucose, o2 sat, ECG, FBC, UECr, Cardiac enzymes, PT, aPTT 4. Management *If ischemic stroke 3 hours within onset, commence thrombolytic therapy (IV alteplase recommended) **Thrombolytic therapy is recommended for ischaemic strokes between 3-4.5 hours as well, although the risk of intracranial haemorrhage is greater in such patients, and the benefits are more modest (earlier treatment is still better). **Contraindications to TPA in acute stroke management ***Significant head trauma or previous stroke in last 3 months ***Symptoms suggest subarachnoid hemorrhage ***CT demonstrates multilobar infarct (hypodensity > ⅓ cerebral hemisphere) ***Arterial puncture in non-compressible site in last 7 days ***History of intracranial hemorrhage ***Intracranial neoplasm, arteriovenous malformation or aneurysm ***Recent intracranial or intraspinal surgery ***Elevated blood pressure (systolic > 185 or diastolic > 110 mmHg) ***Active internal bleeding ***Acute bleeding diathesis (platelets < 100000, heparin therapy with aPTT greater than normal upper limit, current anticoagulation with INR > 1.7 or PT > 15, or current use of direct thrombin/factor Xa inhibitors) ***Blood glucose < 2.7 mmol/L *Correct serum glucose **Hyperglycemia ***may occur even in non-diabetics due to cortisol-mediated stress response. ***worsens clinical outcomes due to increased anaerobic metabolism, lactic acidosis, and free radical production which cause membrane lipid peroxidation and cell lysis. **Hypoglycemia ***can cause focal neurological deficits mimicking stroke. ***administering glucose-containing fluids precipitate acute Wernicke encephalopathy or chronic Korsakoff psychosis. Co-administer thiamine. *Assess swallowing and prevent aspiration *Optimise head position (flat position- ischemic stroke; better cerebral perfusion, bed elevated at 30 degrees for hemorrhagic stroke) *Manage blood pressure **Ischemic stroke treated with thrombolytic therapy ***BP target < 185/110 **Ischemic stroke w/o thrombolytic therapy ***BP target < 220/120 **Hemorrhagic stroke: ***blood pressure low enough to minimise hemorrhage but high enough to perfuse the brain adequately ***keep CPP above 60-70 mmHg **10B guidelines ***After a stroke, initially, the pt will not be given antihypertensives even if his BP is high (unless SBP >200mmHg). This is done to maintain cerebral perfusion ***Only subsequently will anti-hypertensives be started ***Conventional thinking used to be after 14/7, but now it has changed to a few days … exact number is consultant-dependent *Prevent complications **Antithrombotic therapy with aspirin- initiate within 48 hours of ischemic stroke **Prophylaxis of DVT **Statin therapy continue *Also can consider statin therapy Ward Management of Stroke Short Term Prevention and Management Long Term Management Manage risk factors: HLD, AF, HTN, DM *Antiplatelet - for ischemic stroke or TIA (who are not on anticoagulation) **Aspirin **Aspirin with dipyridamole **Clopidogrel *Anticoagulate - for AF or cardioembolic stroke **Warfarin (INR 2-3 for AF, 2-3.5 for prosthetic valve) *Control hyperlipidemia **Simvastatin 40mg if TC > 3.5 (check LFT) *Control hypertension: start if BP > 140/90 (goal: <130/80) **Thiazide **ACEi (check Cr, K+) *DM **OHA, insulin *Lifestyle modifications **Stop smoking (important) - pharmacotherapy include transdermal nicotine patch, nicotine gum, nicotine lozenges, nicotine inhaler, nicotine nasal spray, bupropion, varenicline **Lower salt intake **Lower fat intake **Lower alcohol intake **Increase exercise Rehabilitation of Stroke Stroke rehabilitation *Single issue - outpatient rehab *Multiple issues - inpatient rehab **Other requirements: ***Able to learn and retain ***Medically stable ***Endurance (able to sit supported for ≥ 1h) We use the ICF model to analyse the rehabilitation issues: Restrictions can be tackled by: *Vocational retraining, career counselling *Leisure alternatives Other long-term issues: *Patient and caregiver education *Depression - follow-up with psychiatrist (cognitive-behavioural therapy), family support *Long-term follow-up for residual deficits and risk factor management Done by: CG 28 2013/2014